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Bali Dental Treatment Assessment Form

Step 1 of 6

16%

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Mobile number for Whatsapp(Required)

Email(Required)

Address(Required)

Street Address City State / Province / Region

Are you currently experiencing any of the following?(Required)

Pain

Swelling

Broken teeth

Loose teeth

Difficulty chewing

Missing teeth

Gum problems

None of the above

When was your last dental visit?(Required)

Less than 6 months ago

6–12 months ago

1–2 years ago

More than 2 years ago

Can't remember

Have you previously had any of the following?(Required)

Dental Implants

Crowns

Veneers

Dentures

Root Canal Treatment

Orthodontics

Gum Treatment

None

Section 4 – Medical History

Do you have any significant medical conditions?(Required)

Diabetes

Heart Disease

High Blood Pressure

Sleep Apnoea

Osteoporosis

Cancer History

Autoimmune Disease

None

Other

Please provide details if applicable (medical conditions)

Are you taking any regular medications?(Required)

Yes

No

Do you have any allergies?(Required)

Yes

No

If yes, please provide allergy details

Section 5 – Travel Planning

Are you actively considering treatment in Bali?(Required)

Yes

No

Still Researching

When are you hoping to travel?(Required)

Within 1 month

Within 3 months

Within 6 months

More than 6 months

Not sure

Section 6 – Decision Making

Are you comparing more than one clinic?(Required)

Yes

No

Planning To

What matters most to you?(Required)

Safety

Qualifications

Cost

Reviews

Communication

Hospital Access

Aftercare

Location

What is your biggest concern?(Required)

Infection

Pain

Complications

Appearance

Flying After Treatment

Choosing The Wrong Clinic

Section 6 –Uploads

Upload any documents you have (X-rays, CBCT Scan, Treatment Plan, Previous Quote, Implant Information)

Max. file size: 512 MB.

Upload photos of your teeth or smile

Max. file size: 512 MB.

If you cannot upload here, please email your photos directly to the clinic.

Section 8 – Final Declaration

Is there anything else you would like the dental team to know?

Consent(Required)

I understand this form is for preliminary assessment purposes only and does not constitute medical advice, diagnosis, or a treatment recommendation.

Consent(Required)

I consent to my information being shared with appropriate dental professionals for the purpose of assessing my enquiry.

Signature

Full Name Confirmation(Required)

Full Name

Date(Required)

MM slash DD slash YYYY

A Community Built on Shared Experience

TJC Group’s success has been driven by the willingness of patients to support one another through shared knowledge and lived experience.

Every story contributes to a growing body of information that helps future patients navigate complex healthcare decisions with greater confidence and understanding.

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Important Disclaimer

TJC Group Pty Ltd does not provide medical advice, diagnosis, treatment, or clinical recommendations. All healthcare decisions should be made in consultation with appropriately qualified healthcare professionals. Information provided by TJC Group is intended for educational and informational purposes only.

Medical Disclaimer:

This post is provided for educational purposes only and does not constitute medical or dental advice. Individual treatment requirements, outcomes, risks and suitability vary between patients and should be discussed directly with appropriately qualified healthcare professionals.

Services & Treatment Categories

TJC Group supports Australians seeking information, education, and guidance regarding a broad range of healthcare options available in Bali and Indonesia. The organisation does not provide medical treatment or medical advice, but helps patients understand their options, ask the right questions, and make informed decisions.

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